Workforce profile of Health New Zealand – Te Whatu Ora clinical nurse specialists and nurse practitioners working in the primary area of cardiology between 2024 and 2025

Cardiovascular disease remains a leading cause of mortality and morbidity in Aotearoa New Zealand, particularly among Māori and Pacific populations.¹ Optimal cardiac care requires co-ordinated diagnosis, risk factor modification, timely interventions and long-term multidisciplinary team management across a continuum of healthcare settings.

Within a multidisciplinary model of care, clinical nurse specialists (CNSs) and nurse practitioners (NPs) play a pivotal role. Their advanced clinical expertise contributes to reduced morbidity, mortality and hospital readmissions, resulting in improved patient outcomes and more efficient use of specialist resources.² However, effective workforce planning has been constrained by the absence of nationally consistent data describing the size, scope and distribution of the cardiac CNS and NP workforce across New Zealand. Existing reports provide only partial insights, often limited to specific service areas such as heart failure or primary care NPs. No comprehensive national dataset encompassing CNS and NP roles across all cardiac specialties within Health New Zealand – Te Whatu Ora currently exists.

This study presents the first national overview of the CNS and NP workforce within adult cardiology specialties employed by Health New Zealand – Te Whatu Ora. Understanding of this workforce is essential to identify service gaps, inform future workforce development and guide planning for equitable cardiovascular care.

Methods

A survey was distributed on behalf of the New Zealand Region of the Cardiac Society of Australia and New Zealand (CSANZ) in September 2024 to nurse managers or clinical leads in all public hospitals. The survey requested workforce information including demographics and a report of the number of CNS and NP staff employed in the primary area of adult cardiology inpatient and outpatient services by Health New Zealand – Te Whatu Ora (this did not include paediatric cardiac services). We requested the survey to be completed by one person on behalf of their hospital and returned via email. Data collection occurred between 1 September 2024 and 1 May 2025. Responses were stored in an Excel database.

Data were analysed in Excel, with data reported as total full-time equivalent (FTE), and FTE/100,000 population for each district health board (DHB). The New Zealand population data were obtained from the Health New Zealand – Te Whatu Ora populations web tool.³ To calculate FTE per 100,000 population the following calculation was used: number (x=total FTE) divided by (y=total population) × 100,000.

Workforce ethnicity and age-related data were obtained from the health workforce information programme (HWIP); these were identified by primary area of work (medicine, cardiology and surgery, cardio-thoracic surgery) and/or job title search (cardiac and cardio) as of September 2024.³ There are two standard classification levels of ethnicity data used by Stats NZ Tatauranga Aotearoa (Stats NZ) and the Ministry of Health – Manatū Hauora for collecting and reporting ethnicity information. Level 1 includes five major aggregated ethnic groups, while Level 2 breaks down these groups into more specific subcategories. The usual recommended ethnicity classification when interpreting health-workforce or health-related data is Level 2. However, Level 1 data were provided by HWIP to ensure anonymity given the low volume of the dataset. HWIP utilises a total response approach when collecting ethnicity data, in alignment with best recommended practice.⁴ For this survey, specialty clinical nurses were excluded due to data integration challenges.

In this report, we acknowledge Māori as tangata whenua and affirm Te Tiriti o Waitangi as the foundational document obliging the Crown to uphold a sincere commitment to Māori health and equity of outcomes. We also acknowledge the whakapapa links and ancient connections between Māori and Pacific peoples as Tangata o Te Moana-nui-a-Kiwa, recognised in Health Quality & Safety Commission Te Tāhū Hauora review of Pacific health in New Zealand.⁵ We acknowledge this special relationship between Māori and Pacific peoples, particularly in collective efforts to advocate for equitable health outcomes and a shared commitment to upholding Te Tiriti, while taking due care to avoid homogenisation of distinct needs and requirements in models of care. We use the term Pacific with respect and recognition of the rich diversity of the distinct groups it represents, and the need to support Pacific-focussed workforce planning to achieve equitable outcomes.

Results

Responses were received from all hospital districts in New Zealand and every role in the inclusion criteria was accounted for. There were a reported 132 employees across all the districts, comprised of 113 CNSs and 19 NPs. The total contracted FTE was 104.1, equivalent to 1.99 CNS/NP per 100,000 total population. FTE was greatest in the Northern and Midland Regions (2.40 and 2.37 FTE/100,000 population) and lowest in the Central and South Island Regions (1.86 and 1.10 FTE/100,000 population) (Table 1).

View Table 1–4, Figure 1–2.

Regional variation in CNS and NP FTE also was evident across hospital districts (Table 2, Figures 1 and 2). Detailed comparison between hospital districts would need to consider the geographical location and area of the population and the specific services provided in each DHB, including those providing regional or national cardiac services, which was beyond the scope of the survey. However, there is clear variation across the country, which is best reflected in the total FTE/100,000 population data that range from 4.05/100,000 population in Auckland to the lowest 0.72/100,000 population in Canterbury (Table 2).

Analysis of the workforce data shows a largely mono-cultural nursing workforce that does not reflect the population it serves. Māori nurses comprise 8.3% of employees, significantly below their proportion of the New Zealand population. Pacific representation was suppressed (see Methods), reflecting a very small Pacific workforce, another concerning area of under-representation. Asian CNSs and NPs account for 14.4% of employees and 15.3% of FTE, while CNSs and NPs in the uncategorised “other” ethnicity group make up the majority of the workforce (71.2% of employees and 69.2% of FTE). These patterns show a workforce that does not reflect the diverse ethnic composition of the communities served, particularly for Māori and Pacific peoples, reinforcing ongoing inequities in representation across the sector.⁶

The age distribution of the nursing workforce shows a strong concentration in mid- to late-career age groups, with approximately 50% of employees and of contracted FTE being above the age of 50 (52.2% and 52.9% respectively; Table 4). In contrast, approximately 15% of employees and of contracted FTE are aged below 35 years (15.9% and 15.4% respectively; Table 4). Overall, these data show an ageing workforce profile that poses future sustainability and succession risks.

Cardiac NP workforce data from HWIP dataset

Due to low numbers and to ensure confidentiality these numbers are not reported.

Discussion

The data reveal an unevenly distributed cardiac CNS/NP workforce that falls short of international and local benchmarks. An adequate and appropriately distributed workforce provides the foundational structural requirement for the provision of high-quality care. Without this, any attempts to measure or benchmark quality is hindered. When service demand far outweighs workforce capacity, the proportion of eligible patients who are seen is significantly smaller than what is required, undermining the delivery of high-quality cardiac care for all New Zealanders. This shortfall has direct clinical and economic implications, contributing to delays in diagnosis, initiation and optimisation of guideline-directed therapy, and timely access to specialist cardiac assessment and follow-up. Strong evidence shows NP-led cardiac care improves outcomes and results in cost savings for a health system.⁷

Benchmarking

There are no broadly published recommendations that define CNS/NP workforce capacity across the full spectrum of adult cardiac subspecialties. However, available international heart failure (HF) guidance provides a useful minimum reference point for this subspeciality alone: recommending ≥2 FTE specialist nurses per 100,000 population for heart failure reduced ejection fraction (HFrEF) services alone, increasing to up to 4 FTE when preserved ejection fraction (HFpEF) is included.⁸ In New Zealand, nearly half of regions operate below 1.0 FTE for HF services, while the national combined CNS/NP workforce across all cardiac specialties is only 1.94 FTE per 100,000 population.⁹ This indicates a substantial workforce deficit and limits the ability of services to deliver, measure and benchmark care against international standards.

HF nursing workforce recommendations

HF provides the clearest international example of the evolution toward nurse-led specialist models of care and workforce benchmarking. European Society of Cardiology (ESC) and American College of Cardiology/American Heart Association quality indicators emphasise early initiation and optimisation of guideline-directed medical therapy (GDMT) as key targets linked to improved patient outcomes.¹⁰ The 2023 CSANZ NZ Heart Failure Working Group Position Statement similarly reinforces that equitable and timely GDMT delivery is contingent on an adequately resourced and appropriately trained specialist nursing workforce, an area in which New Zealand remains significantly under-resourced.¹¹

With expanding pharmacotherapy and disease-modifying therapies, HF management has become increasingly complex, with growing patient volume and clinical acuity requiring specialist input.¹² International guidance highlights the importance of rapid GDMT optimisation for HFrEF.^12,13 Specialist cardiac nurses play a central role in achieving this through frequent clinical assessment, patient education, initiation and titration of pharmacotherapy to target doses, safety monitoring and multidisciplinary co-ordination.¹² While nurse-led HF programmes are recommended in ESC guidelines and endorsed by the CSANZ New Zealand Heart Failure Working Group, New Zealand’s overall CNS/NP workforce capacity of 1.94 FTE per 100,000 population across cardiac services highlights a significant resourcing gap and limits the ability to meet contemporary guideline care.^11,12

Equity and Te Tiriti

It is well documented that health professionals can make significant contributions towards achieving equity of outcomes through the delivery of culturally safe care; however, the need for greater diversity within the workforce still needs to be realised.^14,15 One aspect of achieving equity of outcomes is ensuring a culturally safe, diverse health workforce that reflects the populations most in need.¹⁵

Māori make up 17% of the national population, yet hold only 9% of cardiac CNS roles; Pacific peoples made up 8.9% of national population in 2023 and in this study,¹⁴ yet Pacific nurses are nearly absent (to ensure data identity protection this number cannot be published), highlighting the near exclusion of Pacific nurses in senior cardiac CNS and NP roles. These figures highlight that ~70% of the senior cardiac nursing workforce are mono-cultural, herein defined as “other” ethnicity, which is dominantly nurses of NZ European ethnicity, reinforcing dominant cultural perspectives. A recent study of Māori and Pacific patients’ and whānau experiences of heart healthcare made a strong recommendation for a workforce that is representative of the population it serves to provide culturally safe care and to improve equitable health outcomes.¹⁶ The mismatch between the burden of cardiovascular disease carried by Māori and Pacific peoples and their lack of visibility in advanced nursing roles reflects a system that is misaligned with both the Pae Ora (Healthy Futures) Act 2022 and Te Tiriti o Waitangi, requiring a health system that delivers equity in access, experience and outcomes. This under-representation places additional pressure on existing Māori and Pacific nurses to provide cultural guidance and expertise alongside their clinical responsibilities. Advancing systemic cultural change often depends on key individuals within organisations to drive efforts forward, risking burnout and retention of Māori and Pacific nurses.^17,18

Geographic variation

There are marked discrepancies in the distribution of the CNS and NP workforce between the North and South Islands. The South Island comprises 24% of the population but only 13% of CNS/NP FTE and 6% of NP roles.

Interpreting geographic data in isolation is challenging; population need is shaped by multiple factors, including age demographics, deprivation, ethnicity, rurality and access to specialist services such as cardiology, though this complexity does not explain the significant imbalance between the two islands. Tertiary centres may also require higher FTE allocations due to the complexity and volume of services they provide. In contrast, smaller secondary or primary care centres may have fewer senior medical officers (SMOs) on site, which can shift greater clinical responsibility to NPs and CNSs. For example, Tairāwhiti has 1.8 cardiac NPs (3.4 per 100,000 population) and no resident cardiologist, illustrating how workforce models have adapted to meet local service gaps.

An ageing workforce

The high proportion of CNS and NP staff nearing retirement age signals a looming workforce gap, with nearly 40% of FTE held by clinicians over 55 and more than 20% over 60. This represents a significant risk to service continuity, the impending loss of experienced advanced practice nurses jeopardises the continuity of institutional knowledge, clinical leadership and advanced assessment and diagnostic capability. A recent similar survey of Health New Zealand – Te Whatu Ora cardiologists demonstrated a similar ageing demographic.¹⁹ The ageing cardiovascular workforce in New Zealand increases vulnerability to sudden staffing shortages, amplifying existing pressures on already thinly distributed services.

Implications for practice integration and workforce planning priorities

Across New Zealand, we posit that all regions operate below the CNS/NP FTE required to provide timely and co-ordinated cardiac care. Addressing this shortfall requires a national CNS/NP workforce strategy with explicit population-needs-based FTE targets that reflect cardiovascular disease burden, deprivation, ethnicity, rurality, tertiary service demand and access to cardiologists.

Investment should prioritise regions with the greatest unmet need, including the markedly under-resourced Central and South Island Regions. The under-representation of Māori and Pacific nurses in CNS/NP roles, despite these communities experiencing the highest burden of cardiovascular disease, highlights systemic workforce imbalance and breaches of equity obligations. Targeted recruitment, mentoring, postgraduate support and retention pathways for Māori and Pacific nurses are critical to build culturally grounded cardiac leadership and align with Te Tiriti, Pae Ora and New Zealand Health Workforce Plan expectations.²⁰

Transitioning CNSs into NP roles provides clear system benefit, with strong evidence that NP-led cardiac care improves outcomes, reduces hospitalisations and eases specialist waitlists.^2,20 Although the New Zealand Nurse Practitioner Training Support Scheme (NPTSS) funding priorities have recently shifted towards primary care, cardiovascular disease remains a major burden on the healthcare system. Funded NP roles within cardiac teams should be prioritised to improve access to first-specialist assessment, diagnostics, optimise therapy, strengthen service sustainability and support primary care with expert advice. At a minimum, every district should have cardiac NPs integrated within the model of care.

Recommendations

Development of a co-ordinated national cardiac CNS/NP workforce strategy should occur, which includes the following minimum components:

1.       Set explicit FTE requirements

·       Based on population need, deprivation, ethnicity, rurality, tertiary demand and cardiologist availability

2.       Investment in cardiology NP pathways and funded posts

·       Prioritise investment through regional business cases for cardiac NP pathways, strengthening service capacity and sustainability, while reducing first specialist assessment, follow-up waitlists and avoidable admissions, and enhancing holistic patient care

·       Accelerate CNS-to-NP development, essential to protect clinical capacity with an increasingly complex ageing population in the context of rapid cardiac interventions for this cohort

3.       Strengthen Māori and Pacific leadership

·       Develop and resource Māori and Pacific leadership pathways across cardiac nursing, including targeted recruitment, mentoring, education and retention strategies, to build cultural capability and support equity-aligned service delivery consistent with Te Tiriti o Waitangi

4.       Embed succession planning

·       Structured mentoring, clinical education and supported succession into advanced roles are key to retaining specialist knowledge as senior clinicians retire and maintain service stability across regions

Limitations

This study has several limitations. NP-specific ethnicity and age data could not be reported due to HWIP suppression rules for low-volume datasets, which limits the granularity of the analysis for this sub-group. Specialty clinical nurses were excluded because their roles could not be reliably distinguished within HWIP, potentially undercounting some nursing roles. Workforce ethnicity data were provided at Stats NZ Level 1 classification to ensure anonymity; while necessary for privacy, this reduced the ability to interpret variation within specific Māori and Pacific ethnic groups. Subspecialty-level role classification was not collected; inclusion in future datasets would improve the precision of national workforce planning. Workforce definitions were based on local reporting by hospital representatives and job-title search strategies, which may not fully capture newer or evolving models of care. Finally, these data only represent national Health New Zealand – Te Whatu Ora public hospitals and do not include nurse specialists/practitioners employed in primary care or private practice.

Despite these limitations, this represents the most complete national dataset available on cardiac CNS and NP roles, providing an important foundation for future workforce planning and equity-focussed investment.

Conclusions

This national survey demonstrates a critically insufficient and inequitably distributed cardiac CNS and NP workforce that is not aligned with the burden of cardiovascular disease in New Zealand and falls below international benchmarks. The marked disparity between regions, particularly the significant undersupply in the Central and South Island Regions and profound under-representation of Māori and Pacific nurses in senior roles show deep structural inequities in access to specialist cardiac care. These findings highlight a workforce configuration that is inconsistent with Te Tiriti o Waitangi obligations, Pae Ora expectations, and the need for culturally safe, equitable cardiac services.

The age profile of the workforce further underscores the urgency for action, with a large proportion of senior clinicians nearing retirement and limited succession pathways in place. Without a strategic advanced nursing workforce plan mandating population-needs-based CNS and NP FTE across New Zealand, accelerated development pathways for CNS-to-NP roles and targeted investment in Māori and Pacific nursing leadership, cardiovascular service provision will become critically at risk and existing inequities will widen. Strengthening cardiac CNS and NP capacity is therefore not simply a resourcing priority, it is an essential, immediate policy imperative for achieving equitable, timely and high-quality cardiac care across Aotearoa New Zealand.